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MEAL BENEFIT FORM FOR PARENTS (TIER II HOMES) - page 1 / 4

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California Department of EducationChild and Adult Care Food Program

Nutrition Services DivisionNSD 3103 F / DCH 04 (REV. 2/2014)

PAGE 1 of 4

MEAL BENEFIT FORM FOR PARENTS (TIER II HOMES)

Complete, sign, and return this form to the day care home sponsor listed below or your child care provider. See cover letter to give permission.

If you need assistance completing this form, call:

Name of day care home provider:

Part 1–Children’s Information: Enter the name(s) of all children from your household enrolled in your care.

Last Name

First Name

Birthdate

Foster Child *

NSLP, HS, Early HS, Even HS**

*If the foster child receives personal-use income, please enter the amount, and the frequency it is received, in the last column in Part 3.

** If any child in your household participates in Head Start, Early Start or Even Start Programs or is receiving free or reduced price meals in the National School Lunch program, indicate above.

Part 2–Categorical Eligibility (Household): If anyone in your household receives CalFresh (formerly Food Stamps), California Work Opportunity and Responsibility to Kids (CalWORKs), Food Distribution Program on Indian Reservations (FDPIR), or Kinship Guardianship Assistance Payment Program (Kin-GAP), enter that person’s name below, check the appropriate program box and enter the program case number.

Last Name, First Name

Check One

Case Number

CalFresh   CalWORKs   FDPIR   Kin-GAP

Part 3–Income Eligibility (Not required if you reported qualifying program in Part 2.)

Check this box if no one in the household receives income.  

Household Members’ Names

(List all household members not listed in Part 1. If you have foster children in your care, list personal use income of the foster child.)

List Gross Income and how often it was received (e.g., weekly, every 2 weeks, twice a month, monthly, or annually)

Earnings from Work Before Deductions

Alimony, Child Support

Retirement, Pensions, Social Security

All Other Income (include foster child’s personal-use income here)

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

$

Enter the total number of household members

(Children listed in Part 1 + other household members listed in Part 3): _____ (Go to Part 4.)

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